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Abstract

INTRODUCTION: Extended criteria cardiac transplant (ECCT) provides cardiac replacement therapy in patients (pts) with end-stage heart failure who are ineligible for standard criteria transplantation (SCCT). While ECCT provides lower survival, short term outcomes are adequate for pts with advanced age or comorbidities. Long term outcomes after ECCT have not been defined and determining clinical variables associated with improved survival after ECCT will improve risk stratification.

METHODS: 454 pts undergoing cardiac transplantation at Duke University Medical Center from January 2000 until December 2009 were retrospectively analyzed. Each patient was identified as either SCCT (n=370) or ECCT (n=84). Baseline clinical variables included demographics, renal function, and need for circulatory support prior to transplant. Comparisons were made between SCCT and ECCT patients pre-transplant and at years 1 and 5. Survival analysis was performed using standard Kaplan-Meier methods. A Cox proportional hazards model was developed to identify predictors of survival.

RESULTS: Significant differences (P<0.001) in clinical variables between SCCT and ECCT groups included age (53 y vs 66 y), presence of diabetes (25% vs 46%) and ischemic disease (43% vs 70%). Renal function was worse in the ECCT group when assessed by BUN (19 vs 25, p<0.001) but serum creatinine (Cr) was equivalent (1.2 vs 1.3, p=0.027). Mean follow up was 4.7 years and survival is shown in Figure 1. Only serum Cr prior to transplant had a statistically significant effect on survival regardless of the criteria used (p=0.001, HR 1.7, 95% CI 1.25, 2.30).

CONCLUSION: ECCT pts have lower survival than SCCT pts and this risk persists after adjusting for covariates. Serum Cr is an independent predictor of survival in all transplant recipients. Given the detrimental impact of transplant medications on renal function, consideration of Cr should be incorporated in to risk-stratification for patients undergoing ECCT.